Transition of School Based Health Center Benefit and Population into Medicaid Managed Care

Note: Benefit Transition Date no sooner than April 1, 2025

2021 Implementation

  • Document is also available in Portable Document Format (PDF)

July 2018                www.health.ny.gov/mrt                Office of Health Insurance Programs

Table of Contents

  1. Definitions
  2. Scope of the School Based Health Center Benefit
  3. Transitional Care
  4. SBHC/Sponsor Responsibilities
  5. MMCP Responsibilities
  6. SBHC Billing and Reimbursement
  7. Confidentiality
  8. Contracting
  9. Continuity of Services

Overview of Transition

No earlier than January 1, 2021, the provision of School Based Health Center (SBHC) and SBHC-Dental (SBHC-D) Services will be incorporated into the Medicaid Managed Care (MMC) benefit package. Medicaid Managed Care Plans (MMCPs) will be responsible for reimbursing SBHC sponsor agencies for SBHC services provided by SBHCs to MMCP enrollees. The goal of the transition is to maintain access to these critical SBHC and SBHC-D services while integrating the services into the larger health care delivery system. It is anticipated that the integration of SBHC and SBHC-D services within the existing managed care framework, and coordination of services with the child´s primary care provider, will improve quality and promote an efficient, effective delivery system. Maintaining the continuity of care, and the wellness of the child, to facilitate learning and improve school attendance is of utmost importance in this transition.

The following guidelines identify the scope of benefits, the roles and responsibilities of MMCPs and SBHCs, network responsibilities, and claims coding.

The policies outlined in this document were developed with significant input from both SBHCs and MMCPs. This input will guide the transition of SBHC services into managed care over a two–year period. However, it is recognized that certain policies may require modification during the transition and that there may be a need to retain certain policies beyond the two–year transition period. NYSDOH will continue to consult with SBHC and MMCP stakeholders regarding program policy during, and subsequent to, the transition to ensure that the goals of maintaining access to services, improving integration, continuity of care, and promoting quality improvement and efficiency in care delivery, are met.

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I. Definitions

Medicaid Managed Care Plan (MMCP) is a Health Maintenance Organization (HMO) or Prepaid Health Services Plan (PHSP) certified by the Department of Health under Article 44 of the Public Health Law, and responsible for the provision of comprehensive covered health services to eligible persons residing within the MMCP’s contracted service area.

SBHC Sponsors are the licensed Article 28 facilities whose extension clinics (i.e. SBHCs) provide direct service. SBHC sponsors are responsible for the administration and operation of SBHCs, ensuring that policies and procedures are in accordance with the New York State SBHC Principles and Guidelines Document.

Memorandum of Understanding Requirement (MOU) is a formal written agreement between the governing authority of the school district and the Article 28 facility that is sponsoring the SBHC which serves the students within the school. In order for a SBHC, or SBHC–D, program to operate in NYS, the Article 28 sponsor must have a Memorandum of Understanding (MOU) with the school where the clinic will be located. In New York City, the Article 28 sponsor must have a MOU with the New York City Department of Education.

School–Based Health Centers (SBHC) are clinics operated by a facility licensed under Article 28 of the Public Health Law and located within a school building.

School–Based Dental Health Centers (SBHC–D) are clinics operated by a facility licensed under Article 28 of the Public Health Law that provide dental services within a school building or campus (i.e. Mobile Vans). SBHC–D services may be provided at dental–only SBHC–D sites, or may be provided in combination with other health care services at a SBHC site.

SBHC Services include both core and enhanced services provided by SBHCs pursuant to their operating certificate. In accordance with NYSDOH guidelines, all SBHCs are required to provide a core of basic primary and preventive care services including: health maintenance/well–child care; diagnosis and treatment of injury and acute illness; and diagnosis, and management, of chronic disease. In addition, SBHCs may provide enhanced services and health education as outlined in the SBHCs Principles and Guidelines document.

http://www.health.ny.gov/facilities/school_based_health_centers/docs/principles_and_guidelines.pdf

SBHCs that do not offer behavioral health and reproductive health services on–site in the SBHC are required to provide referrals for those services.

SBHC–D Services include diagnostic and preventative treatment, restorative procedures, endodontics, limited periodontics, prosthodontics, oral and maxillofacial surgery, and orthodontics.

Family Planning and Reproductive Health Services mean the offering, arranging, and furnishing of health services which enable Medicaid Managed Care Enrollees (including minors) who may be sexually active, to prevent or reduce the incidence of unwanted pregnancies and sexually transmitted infections.

  1. Medicaid fee for service covered family planning services include:
    1. Most FDA approved birth control methods, devices, and supplies (e.g., birth control pills, injectables, patches, condoms, diaphragms, implants, and IUDs)
    2. Emergency contraception services and follow–up care
    3. Preconception counseling, preventive screening, and family planning options before pregnancy
  2. The following additional services are considered family planning only when provided within the context of a visit with the primary diagnosis of family planning (Z30) and when the service provided is directly related to family planning:
    1. Pregnancy testing and counseling
    2. Comprehensive health history and physical examination, including breast exam and referrals to primary care providers as indicated (mammograms are not covered)
    3. Screening and treatment for sexually transmitted infections (STIs)1
    4. Screening for cervical cancer, and urinary tract or female–related infections
    5. Screening and related diagnostic laboratory testing for medical conditions that affect the choice of birth control, e.g., a history of diabetes, high blood pressure, smoking, blood clots, etc.
    6. HIV counseling and testing
    7. Counseling services related to pregnancy, informed consent, and STI/HIV risk counseling
    8. Bone density scan (only for women who plan to use, or are currently using, Depo–Provera)
    9. Ultrasound (to assess placement of an intrauterine device)
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II. Scope of the School Based Health Center Benefit

  1. SBHC Services that will be covered through the MMCP include all those listed under SBHC, and SBHC–D, service definitions above, with the following exception:
    1. Family Planning and Reproductive Health services as defined above will remain carved out of the MMCP.
  2. Students enrolled in MMCPs will have direct access to all services provided by SBHCs, and SBHC– Ds, without the need for referral or prior authorization, with the following exceptions:
    1. Dental Health

      Routine preventive services, such as, sealants, fillings, fluoride treatments, simple extractions (which includes the elevation and/or forceps removal of an erupted tooth or an exposed root) and cleanings provided in SBHC–D sites do not require prior authorization. MMCPs may choose to require prior authorization for dental services that include more extensive care, such as root canals, crowns, dentures, fixed partial dentures, impactions and surgical extractions, and orthodontic treatment. SBHC–D programs that provide these additional services should consult with MMCPs and/or dental benefit vendors for plan–specific requirements.
    2. Behavioral Health
      1. Routine primary behavioral health visits such as an initial assessment, psychiatric diagnostic evaluation; individual psychotherapy; psychotherapy with patient and/or family member; psychotherapy for crisis; family psychotherapy; group psychotherapy; pharmacologic management; tele–psychiatry services; and health and behavior assessment/intervention related to physical health problems, provided in SBHC sites do not require prior authorization.
      2. MMCPs may require prior authorization for the following testing and treatment services: psychological, neurobehavioral, neuropsychological, developmental testing, and intensive psychiatric treatment. SBHC programs providing these additional services under their sponsor’s Article 28 license should consult with MMCPs, and/or the MMCPs’ behavioral health benefit vendors, for plan–specific requirements.
    3. During the 2–year transition period, MMCPs may not require concurrent review authorization, or conduct retrospective utilization review, for SBHC services.
    4. SBHCs and MMCPs will work collaboratively on quality improvement initiatives, including information sharing to improve outcomes for an individual child.
  3. The MMCP and SBHC will develop a process to share information relating to the provision of services to children. The MMCP will work with the SBHC, and the child’s Primary Care Provider [PCP] (if not the SBHC), to assist in promoting wellness, and ensuring that all children receive recommended well child visits and other needed services.
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III. Transitional Care

  1. During the transition of SBHC services to managed care, it is expected that the provision of SBHC, and SBHC–D, services to students will be maintained.
    1. The Department will assess the status of contracting efforts between SBHCs and MMCPs, and overall network readiness 90 days prior to the implementation date, and take corrective action, if necessary.
    2. For SBHCs and SBHC–Ds that do not have executed contracts after 90 days of having completed all necessary documentation, and do not have executed contracts with MMCPs at the time of the implementation date, each party will continue to demonstrate good faith and participation in the process to contract for SBHC/SBHC–D services. During this continued negotiation period, the parties will mutually agree to one of the following payment mechanisms:
      1. the MMCP will reimburse the SBHC//SBHC–D retrospectively for covered services provided from the provider´s fee for service Medicaid enrollment begin date as approved by OHIP to the date network participation is established, without regard to timely requirements; or
      2. the SBHC/SBHC–D will bill and be reimbursed by the MMCP concurrently on an out of network basis for services provided by the health professional to the MMCP´s enrollees effective with the date the application is received by the MMCP, until the date network participation is established.
      3. if there is no agreement by the parties, the Department will establish a mechanism to ensure timely and appropriate payment for SBHC/SBHC–D services through an individualized corrective action plan with the MMCP.

The requirements in 1(a) and 1(b) above apply to MMCPs and their sub–contracted benefit management vendors.

  1. MMCPS will permit enrollees who are in an on–going course of care at a SBHC at the time of the transition of these services to managed care, to continue their course of treatment unchanged for six months. Six months after the effective date, all changes to on–going care will occur in a manner consistent with section II(c).
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IV. SBHC/Sponsor Responsibilities

SBHC and SBHC–D sponsors will be required to contract with all MMCPs in their service area. For benefits managed by subcontractors, such as dental and behavioral health, the sponsor will be required to contract with those subcontractor(s) identified by the MMCP. Federally Qualified Health Centers (FQHC’s) are not required to contract with all MMCPs in their service area. For visits that are either unpaid, or occur outside a contract between the FQHC and MMCP, the State will reimburse the FQHC at the full FQHC rate, per the New York State Department of Health’s, “NYS Managed Care Supplemental Payment Program for FQHCs Policy Document.”

  1. SBHCs and SBHC–Ds will work with the sponsoring facility to have their SBHC staff credentialed.
  2. SBHCs and SBHC–Ds will share the roster of students enrolled in the SBHC/SBHC–D with the appropriate MMCPs to help determine which students are in need of a comprehensive physical exam and/or other services.
  3. SBHCs and SBHC–Ds will obtain all consents needed in order to provide services.
  4. SBHCs will be required to provide member health record information to MMCPs as needed specifically for reports required by the New York State Department of Health, or any designee of the Department of Health for Quality Assurance Reporting Requirements (QARR).
  5. SBHCs will assist MMCPs in improving required performance measures.
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V. MMCP Responsibilities

  1. MMCPs will contract with all Article 28 sponsors of SBHC/SBHC–D in their service area who are willing to contract with the MMCP. MMCPs operating in any borough of New York City will contract with all Article 28 sponsors of SBHC/SBHC–D services in New York City who are willing to contract with the MMCP. For children living away from home for extended periods of time, the MMCP and Article 28 sponsor may consider executing a single case agreement. MMCPs will assist SBHCs in securing necessary contracts with the MMCP’s sub–contracted benefit vendors.
  2. MMCPs will work with SBHCs to improve enrollee health outcomes.
    1. MMCPs will use rosters provided by SBHCs and SBHC–Ds to identify enrollees that are in need of comprehensive exams or other services.
    2. MMCPS will provide data to SBHCs to help SBHCs target enrolled children who have not had an annual history and physical exam, and/or other well child services.
  3. MMCPs must have a process in place to ensure timely credentialing of SBHC providers will occur in compliance with the MMC model contract and NYS Public Health Law §4406–d(1)(a). MMCPs will accept an Article 28 sponsor´s credentialing of a SBHC/SBHC–D provider. MMCPs will have processes in place to expedite credentialing of SBHC/SBHC–D health care professionals where the SBHC/SBHC–D indicates access to care for the MMCP´s enrollees will be adversely impacted or interrupted by following the standard credentialing time frames. Once credentialed, or provisionally credentialed, as per NYS Public Health Law §4406–d(1)(a), the MMCP and the SBHC/SBHC–D will mutually agree to one of the following payment mechanisms, or the Department will establish a mechanism to ensure timely and appropriate payment for SBHC/SBHC–D services, through an individualized corrective action plan established with the MMCP:
    1. the MMCP will reimburse the SBHC//SBHC–D retrospectively for covered services provided from the provider´s fee for service Medicaid enrollment begin date as approved by OHIP to the date network participation is established, without regard to timely requirements; or
    2. the SBHC/SBHC–D will bill and be reimbursed by the MMCP concurrently on an out of network basis for services provided by the health professional to the MMCP´s enrollees effective with the date the application is received by the MMCP, until the date network participation is established.
  4. MMCPs will reimburse SBHCs as outlined in section VI “SBHC Billing and MMC Reimbursement.”
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VI. SBHC Billing and MMCP Reimbursement

  1. SBHCs and SBHC–Ds will submit claims to MMCPs for all SBHC and SBHC–D services provided to MMC enrollees with the exception of Family Planning and Reproductive Health Services.
  2. All claims submitted by SBHCs must have a valid primary diagnosis noted on claim.
  3. As per the two–year commitment for reimbursement, MMCPs must reimburse SBHC and SBHC–D providers at the current applicable Medicaid fee–for–service rates for two years after the implementation of the transition to managed care.
    1. Throughout the transition period and continuing thereafter, SBHCs/SBHC–Ds sponsored by Federally Qualified Health Centers (FQHC) that do not participate in the Ambulatory Patient Groups (APGs) will be reimbursed utilizing the Prospective Payment System (PPS) rate and wrap–around rate per the New York State Department of Health’s NYS Managed Care Supplemental Payment Program for FQHCs Policy Document.
    2. All SBHC/SBHC–D providers other than FQHCs that utilize the PPS rate, will be reimbursed utilizing the rate that applies to the current Ambulatory Patient Groups (APGs) that SBHCs receive in the Medicaid fee–for–service system.
  4. For dental and mental health benefits managed by a MMCP through a sub–contractual relationship, the SBHC may be required to directly bill the subcontractor as indicated by the MMCP.
  5. Family Planning and Reproductive Health Services delivered at SBHCs will be “carved–out” of the Medicaid Managed Care Benefit Package at this time as defined in Section I of this policy guidance.
  6. Billing and reimbursement for services provided by SBHCs and SBHC–Ds to MMC enrollees will occur in accordance with the New York State Department of Health’s NYS Mainstream Medicaid Managed Care and School Based Health Center Billing Guidance.
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VII. Confidentiality

Purpose: To provide an effective, uniform, and systemic mechanism for Medicaid Managed Care Plans (MMCPs) to comply with confidentiality protections for health care services provided to minors who are enabled by statute to consent to their own heath care.

MMCPs are required through federal and NYS statute and regulations to prevent unauthorized disclosure of their enrollees’ protected health information. Minors are entitled to the same, or stricter, confidentiality protections for certain services or under certain conditions. These include, but are not limited to: the Health Insurance Portability and Accountability Act; 42 CFR §2.14; NYS Public Health Law §§18, 2305(2), 2306, and 2504(1); NYS Public Health Law Article 27–f; NYS Mental Hygiene Law §§22.05(b), 22.11(c), 33.13, and 33.16; 18 NYCRR §360–8; and Carey v Population Services International, 431 U.S. 678 (1977).

MMCPs are also required to provide enrollees with written notice of all adverse Actions, including when payment of a claim is denied. The Notice of Action describes the enrollee’s appeal rights and right to fair hearing should the enrollee disagree with the MMCP’s determination.

The Department believes that, to the extent possible, targeted suppression of these claim denial notices is necessary to meet statutory requirements to protect the confidentiality rights of adolescents and foster access to family planning, HIV testing, sexually transmitted disease treatment, mental health services, and substance use disorder treatment.

  1. For claims processed and paid by MMCPs, the MMCP will suppress denial notices and Explanation of Benefits for enrollees in accordance with the Department’s Policy for the Protection of Confidential Health Information for Minors Enrolled in NYS Medicaid Managed Care Plans.
  2. For claims processed and paid by the state for Medicaid fee–for–service payment, no Explanation of Benefits (EOB) or other notification will be sent to the enrollee.
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VIII. Contracting

  1. Contracts will be executed between the MMCPs and the Article 28 facilities that sponsor the SBHCs. MMCPs that currently have provider agreements with the Article 28 sponsors may modify existing contracts with sponsoring facilities to include the facilities’ SBHCs.
  2. SBHCs will be listed as approved sites for care in MMCP provider directory and promotional materials.
  3. All agreements between the sponsoring entity and the MMCP will reflect all SBHC sites that are sponsored by the Article 28 facility. A separate agreement is not required for each SBHC site.
  4. If the MMCP is utilizing a previously approved contract with an Article 28 facility, the contract will not have to be submitted to the Office of Health Insurance Programs (OHIP) for review and approval. If the contract was not previously approved, it must be submitted to the OHIP prior to execution.
  5. For benefits managed by subcontractors, such as dental and behavioral health, the sponsor may be required to contract with the subcontractor identified by the MMCP.
  6. The designation of SBHCs as PCPs is permitted and will be determined on a case–by–case basis between the MMCPs and the SBHC sponsoring facilities. However, no SBHC will be required to be a PCP as a condition of participation. The MMCP designating an SBHC as PCP must ensure the SBHC maintains the responsibilities similar to those of other network PCPs. Those responsibilities include, but are not limited to, disease management, referrals, hours of availability, and access to care on a full–year basis.
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IX. Continuity of Services

  1. The NYS DOH’s Division of Family Health and Office of Health Insurance Programs will continue to meet with the SBHC MMC Workgroup to ensure a smooth transition of SBHC and SBHC–D services, and payments, from Medicaid fee–for–service to the MMC benefit package to ensure students have continued access to health care services.
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1. These services are covered as non–family planning medical benefits within MMC when delivered outside the context of a visit with a primary diagnosis of family planning. 1